Running head: EVALUATING THE EFFECTIVENESS 1 · Jenny L. Owens REBOOT Combat Recovery Matthew B....

Running head: EVALUATING THE EFFECTIVENESS 1

Evaluating the Effectiveness of REBOOT Combat Recovery:

A Faith-Based Combat Trauma Resiliency Program

Leanne K. Knobloch

University of Illinois

Leonard N. Matheson

EpicRehab

Jenny L. Owens

REBOOT Combat Recovery

Matthew B. Dodson

Braintrust Services

Author Note

Leanne K. Knobloch, Department of Communication, University of Illinois; Jenny L.

Owens, REBOOT Combat Recovery; Leonard N. Matheson, EpicRehab; Matthew B. Dodson,

Braintrust Services.

This research was supported in part by the Bob Woodruff Foundation and the

Montgomery County Community Health Foundation. The authors are grateful to John Dale,

Marie Elder, Hope Gilbert, Christine Manville, Rachel Moore, Evan Owens, and Sheridan Seitz.

Address correspondence to Leanne K. Knobloch, Department of Communication,

University of Illinois, 3001 Lincoln Hall, 702 South Wright Street, Urbana, IL, 61801.

Telephone: 217-333-8913. E-mail: [email protected].

This is an Accepted Manuscript of an article published by Taylor & Francis in Military

Psychology on 7/1/2019, available online: http://www.tandfonline.com/10.1080/08995605.2019.1630228

EVALUATING THE EFFECTIVENESS 2



Abstract

Evidence-based intervention programs attuned to the spiritual needs of service members,

veterans, and their families are needed to help them deal with the potentially debilitating

consequences of combat trauma. This study evaluated the effectiveness of a faith-based, peer-led

combat trauma resiliency program called REBOOT Combat Recovery. Participants were 254

adults who reported on 8 aspects of physical, mental, and social well-being during the 3rd week

and the 12th week of the program. Findings indicated improvement for pain interference, fatigue,

sleep disturbance, anxiety and depressive symptoms, and social participation. Improvement was

uniform except that veterans benefited more than currently serving military personnel with

respect to anxiety symptoms. These results suggest the program may be effective for coping with

the aftermath of combat trauma.

Keywords: combat trauma, health, military, REBOOT Combat Recovery, spirituality

Public significance statement: Participants in the REBOOT Combat Recovery program

reported improvement in their pain interference, fatigue, sleep disturbance, anxiety and

depressive symptoms, and social participation. These findings imply that the REBOOT Combat

Recovery program may be useful for helping military service members, veterans, and their

family members deal with combat trauma.




Combat trauma, which may result from exposure to dangerous and/or disturbing events

in a warzone (e.g., Shea, Presseau, Finley, Reddy, & Spofford, 2017; Stein et al., 2012), can take

a considerable toll on military personnel and veterans. Not only can it diminish people’s

psychological and physical well-being, but it can upend their belief system and moral code

(Smith-MacDonald, Norris, Raffin-Bouchal, & Sinclair, 2017). For example, combat trauma is

associated with posttraumatic stress (Jakob, Lamp, Rauch, Smith, & Buchholz, 2017), mental

health symptoms (Fritch, Mishkind, Reger, & Gahm, 2010), social anxiety (Kimbrel et al.,

2016), and alcohol problems (Vest, Homish, Hoopsick, & Homish, 2018). Combat trauma,

particularly exposure to killing and war atrocities, also is associated with suicidality (Bryan et

al., 2015). Further, combat trauma has effects beyond service members by putting spouses and

children at risk of developing secondary trauma stress (Herzog, Everson, & Whitworth, 2011).

Spiritual care has received increasing attention for addressing combat trauma (Maguen et

al., 2017; Sherman, Harris, & Erbes, 2015; Wortmann et al., 2017). A growing body of research

documents a link between spirituality and military readiness (Smith-MacDonald et al., 2017).

Moreover, spiritual fitness is a key domain in both the U.S. Army Comprehensive Soldier

Fitness model (Cornum, Matthews, & Seligman, 2011) and the DoD Total Force Fitness model

(Jonas et al., 2010). Both initiatives highlight constructs such as valuing service, maintaining

positive beliefs, making meaning, leading ethically, and respecting diversity (Jonas et al., 2010).

These developments over the past decade spotlight the importance of spiritual care for enhancing

the resilience of service members (Thomas, McDaniel, Albright, Fletcher, & Koenig, 2018).


The REBOOT Combat Recovery program (www.rebootrecovery.com/) is a manualized

combat trauma resiliency course designed to help participants cope with the aftermath of war.

The 12-week peer-led program uses Christian principles to enhance resilience among military

personnel, veterans, and their family members dealing with combat trauma. Despite anecdotal

evidence of its success, the REBOOT program has not been subject to empirical evaluation. Our

goal is to evaluate the effects of the program on the physical, mental, and social health of service

members, veterans, and their caregivers. To that end, we conducted a study of 254 adults who

completed the program in 44 locations across the country.

Combat Trauma and Spirituality

Aversive experiences in the line of duty can generate combat trauma (Hoge et al., 2004;

Stein et al., 2012), including being in danger, observing the aftermath of violence, experiencing

traumatic loss, and committing or witnessing a morally offensive act (Shea et al., 2017; Stein et

al., 2012). Sizeable numbers of service members deployed to Iraq or Afghanistan report being

attacked or ambushed, shooting at the enemy, knowing someone injured or killed, and seeing ill

or injured civilians but being unable to help (Hoge et al., 2004). Military service in a warzone

can lead people to see and do things that challenge their ethical values (Drescher et al., 2011;

Litz et al., 2009; Wortmann et al., 2017).

Participation in combat can have long-term implications for the spirituality of service

members (Currier et al., 2017; Purcell, Koenig, Bosch, & Maguen, 2016). Spirituality refers to

service members’ personal belief system related to the meaning of life and possibly faith in a

higher power (e.g., Sherman et al., 2015; Smith-MacDonald et al., 2017; Thomas et al., 2018).

Spirituality is central to occupational performance in general (Baum, Christiansen, & Bass,

2015) and military readiness in particular (Cornum et al., 2011). Moral injury has been defined


as the inner conflict that can occur when people are involved in situations that transgress their

deeply held moral beliefs (Drescher et al., 2011; Litz et al., 2009). Service members report

grappling with guilt, hostility, and aggression long after returning home from combat (Dennis et

al., 2016). In the words of a Vietnam veteran: “I feel proud to be a soldier who tried to do

something that I thought was right for the country. But it’s hard to be a soldier. It tears away

from your moral fiber. It changes your life” (Purcell et al., 2016, p. 1079).

The strong links between combat trauma, spirituality, and moral injury (e.g., Currier et

al., 2017) highlight the importance of programs that address the spiritual repercussions of

military service. A great need exists for spiritual interventions designed to help military

personnel and veterans deal with the aftermath of witnessing, perpetrating, and/or failing to

prevent objectionable activity (Sherman et al., 2015; Smith-MacDonald et al., 2017). For

example, Purcell et al. (2016) encouraged efforts to “help veterans connect with one another by

creating or advocating for venues that bring veterans together to explore the moral and spiritual

dimensions of war’s violence” (pp. 1091-1092). REBOOT is designed to provide such services.

The REBOOT Combat Recovery Program

The REBOOT Combat Recovery program is a 12-week manualized course that relies on

Christian principles to address whole-person wellness for those affected by combat trauma. The

program is open to current and veteran service members of all eras, branches, and ranks. It is

offered to participants free of charge by REBOOT Alliance, a 501(c)(3) nonprofit organization,

in more than 150 locations throughout the United States, Australia, and Germany. The program

was developed in 2011 by a civilian Army hospital occupational therapist to fill a gap in the

treatment of military combat trauma by targeting the spiritual wounds of war. Its goals are to

educate, affirm, and support those dealing with combat trauma and their families.


REBOOT is grounded in three theoretical frameworks. Following the transtheoretical

model of health behavior change (Prochaska, Wright, & Velicer, 2008), the program recognizes

that people vary in their readiness to make changes in their lives, and the curriculum is designed

to help them move through sequenced stages of behavior modification. Guided by social-

cognitive theory (Bandura, 1986), the program seeks to enhance learning through observation,

motivation, and self-efficacy. Informed by the occupational therapy practice framework

(American Occupational Therapy Association, 2014), REBOOT works to facilitate engagement

in personally meaningful activities as central to the ability to thrive.

Five core values infuse the program. First, it uses Christian Biblical concepts to reframe

adversity as an opportunity for growth rather than distress. Second, it cultivates a culture of trust

by relying on course leaders who have personal experience with combat trauma, by emphasizing

equality regardless of rank, and by upholding confidentiality. Third, because combat trauma

affects the entire family (Herzog et al., 2011), REBOOT welcomes spouses, children, and loved

ones of service members and veterans. Fourth, the program encourages Christian fellowship to

foster supportive relationships among participants who share similar experiences. Finally, it

offers volunteer opportunities for graduates to serve others who are dealing with combat trauma.

REBOOT has a manualized curriculum (Owens & Owens, 2016) taught in each location

by a trained leadership team with military experience. Staff members at the REBOOT national

headquarters oversee the selection and education of the course leaders, who become certified by

completing a formal training program and then receive ongoing support.

Weekly sessions are held at locations such as military installations, VA hospitals,

churches, prisons, and community centers. Each session begins with a family-style meal to

facilitate fellowship. After children begin childcare activities, participants engage in an ice-


breaker activity and watch a short video introducing the session topic. Then, the course leaders

teach the curriculum presented in the manual for approximately 40 minutes using a combination

of lecture and discussion strategies. Participants follow along using a field guide workbook

containing Scripture passages, discussion questions, and reflection activities. Sessions conclude

with an experiential “homework challenge” for the upcoming week and a closing prayer of

thanksgiving and petition for the needs of the group.

The curriculum topics are (a) an introduction to the spiritual wounds of war, (b) the roots

of trauma, (c) humility in healing, (d) making wise decisions, (e) gaining freedom from guilt, (f)

forgiveness, (g) grief and loss, (h) depression and suicide, (i) rebuilding a positive self-identity,

(j) dealing with discouragement, (k) sharing your story, and (l) the graduation ceremony (see

online supplement Table A). Scripture passages from both the Old Testament and the New

Testament are incorporated into each session to illustrate key points. Although the curriculum is

grounded in Christian principles, the program is open to attendees of all faith and no faith

backgrounds, and course leaders are trained to foster an atmosphere that is inclusive and

respectful. The retention rate for attendees averages 81.5% from Week 1 to Week 12.

The REBOOT Combat Recovery program seeks to help those dealing with combat

trauma to live in a purposive, hopeful, and socially connected way. Evidence of improvement in

these areas may include diminished physical suffering, reduced anxiety and depression, and

increased social and community involvement. Accordingly, we hypothesize that people

completing the program will report improved physical health (H1), mental health (H2), and

social health (H3). We also pose two research questions to investigate who benefits the most

from the program: What personal characteristics (RQ1) and military characteristics (RQ2), if

any, predict more improvement from the program?


Method

People enrolled in the REBOOT program from the spring of 2016 through the spring of

2018 completed measures of their well-being during the 3rd week and the 12th week of the

program. The 3rd week was selected for the first questionnaire so course leaders could build

rapport before asking participants to provide sensitive information. Although our study lacks a

true pretest-posttest control group design, the delayed administration of the baseline measures

means that our investigation may be less susceptible to the response shift bias that can plague

traditional pretest-posttest comparisons (e.g., Pratt, McGuigan, & Katzev, 2000). Data collection

and confidentiality procedures were approved by the relevant Institutional Review Boards.

Procedures

Recruitment and data collection occurred after the fellowship meal during program

sessions. Course leaders described the study, the voluntary nature of participation, and the

confidentiality of responses. Attendees had time to review written materials and ask questions

before deciding if they wanted to participate. Those who chose to participate completed informed

consent documents before beginning.

Participants completed the questionnaires online or in hard copy. The Week 3

questionnaire solicited demographic information and ratings of well-being. The Week 12

questionnaire asked about session attendance and included the same ratings of well-being. Both

questionnaires took approximately 20 minutes to complete. No incentives were offered.

Participants

The sample contained 254 adults (138 men, 116 women) who graduated from the

REBOOT program and completed both the Week 3 and Week 12 questionnaires. Participants


represented 67 small groups hosted in 44 locations across 18 U.S. states and the District of

Columbia. They completed the study in 2016 (24.8%), 2017 (61.0%), or 2018 (14.2%).

Participants ranged in age from 20 to 89 years old (M = 43.55 years, SD = 13.83 years).

They described their relationship status as single (6.5%), dating (6.1%), engaged to be married

(1.0%), married (65.8%), separated (5.5%), divorced (12.1%), widowed (2.0%), or other (1.0%).

The majority of participants were completing the course for the first time (87.4%), while others

were repeating the course (12.6%). On average, they attended 10.67 of the 12 sessions (range = 5

to 12 sessions, SD = 1.52 sessions). Attendance percentages were five (0.8%), six (0.8%), seven

(2.9%), eight (5.0%), nine (11.6%), ten (14.0%), eleven (24.8%), or twelve (40.1%) sessions.

Participants reported their employment status as currently employed (55.3%), retired

(19.1%), homemaker (7.6%), unable to work (7.0%), out of work and looking for employment

(5.0%), out of work and not looking for employment (3.0%), or attending school (3.0%).

Of the 254 participants, 146 (57.5%) had experienced military combat trauma, 92

(36.2%) were caregivers of a person with military combat trauma, and 16 (6.3%) attended in a

civilian capacity (e.g., individual with civilian trauma, clinician).

Characteristics of participants with military combat trauma. The subsample of 146

participants with military combat trauma contained 120 men (82.2%) and 26 women (17.8%). A

total of 27.4% were currently serving in the military, and 72.6% were veterans. They were

affiliated with the Army (65.0%), Navy (10.9%), Air Force (9.5%), or Marines (14.6%). They

averaged 19.20 months (SD = 15.13) of combat deployment during their military career.

Characteristics of caregivers. The subsample of 92 caregivers contained 16 men (17.4%)

and 76 women (82.6%). Most caregivers were civilians (78.3%), but others were currently

serving (4.3%) or had previously served (17.4%) in the military.


Characteristics of civilian attendees. The subsample of 16 participants who attended in a

civilian capacity had experienced civilian trauma or were behavioral health professionals. The

group contained 2 men (12.5%) and 14 women (87.5%).

Measures of Physical, Mental, and Social Health

Participants completed the Patient-Reported Outcomes Measurement Information System

(PROMIS-29 v2.0) to report their physical, mental, and social health. PROMIS-29 v2.0 assesses

eight domains of wellness: (a) five aspects of physical health (physical function, pain

interference, pain intensity, fatigue, and sleep disturbance), (b) two aspects of mental health

(anxiety symptoms and depressive symptoms), and (c) one aspect of social health (ability to

participate in social roles and social activities). The PROMIS measures were developed through

extensive testing, contain excellent psychometric properties, and possess substantial evidence of

validity (see Hays, Spritzer, Schalet, & Cella, 2018).

Physical function. Four items operationalized physical function: (a) are you able to do

chores such as vacuuming or yard work? (b) are you able to go up and down stairs at a normal

pace? (c) are you able to go for a walk of at least 15 minutes? and (d) are you able to run errands

and shop? (1 = unable to do, 5 = without any difficulty).

Pain interference. Items assessing the degree to which pain limited participants’ daily

activities completed the stem “In the past seven days …” (a) how much did pain interfere with

your day to day activities? (b) how much did pain interfere with your work around the home? (c)

how much did pain interfere with your ability to participate in social activities? and (d) how

much did pain interfere with your household chores? (1 = not at all, 5 = very much).

Pain intensity. The following item assessed pain intensity: In the past seven days, how

would you rate your pain on average? (0 = no pain, 10 = worst imaginable pain).


Fatigue. Four items measuring fatigue began with the stem “In the past seven days …”

(a) I feel fatigued, (b) I have trouble starting things because I am tired, (c) how run down do you

feel on average? and (d) how fatigued are you on average? (1 = not at all, 5 = very much).

Sleep disturbance. Items addressing sleep disturbance followed the stem “In the past

seven days …” (a) my sleep quality was (1 = very poor, 5 = very good), (b) my sleep was

refreshing, (c) I had a problem with my sleep, and (d) I had difficulty falling asleep (1 = not at

all, 5 = very much). We reverse-scored responses to the first and second items.

Anxiety symptoms. Four items assessing anxiety symptoms completed the stem “In the

past seven days …” (a) I felt fearful, (b) I found it hard to focus on anything other than my

anxiety, (c) my worries overwhelmed me, and (d) I felt uneasy (1 = never, 5 = always).

Depressive symptoms. Items measuring depressive symptoms were introduced by the

stem “In the past seven days …” (a) I felt worthless, (b) I felt helpless, (c) I felt depressed, and

(d) I felt hopeless (1 = never, 5 = always).

Ability to participate in social roles and activities. Four items solicited ratings of social

participation: (a) I have trouble doing all of my regular leisure activities with others, (b) I have

trouble doing all of the family activities that I want to do, (c) I have trouble doing all of my usual

work (include work at home), and (d) I have trouble doing all of the activities with friends that I

want to do (1 = always, 5 = never).

We followed the recommended scoring procedures for the PROMIS by (a) analyzing the

raw scores for pain intensity, and (b) summing the responses to the individual items to form

subscales for the other measures (Hays et al., 2018).

Results

Preliminary Analyses


Bivariate correlations indicated overlap among the well-being measures for both the

Week 3 and the Week 12 ratings (see online supplement Table B). The within-person

correlations ranged from r = .60 to r = .80, all p < .001.

Because the PROMIS measures offer a normed metric via standardized t scores (M =

50.00, SD = 10.00), we calculated one-sample t tests to compare participants with the national

average (see online supplement Table C). Our sample reported worse functioning than the

general U.S. population in all aspects of well-being except social participation at Week 12.

Finally, we conducted paired-samples t tests comparing well-being at Week 3 versus

Week 12 in the raw metric (see Table 1). Findings showed improvements in all aspects of well-

being except physical function. The absolute value of the effect size d corrected for the

correlation between Week 3 and Week 12 (following Morris & DeShon, 2002, p. 111) for the

measures showing improvement ranged from .17 to .53.

Substantive Analyses

We used multilevel modeling for the substantive analyses to account for the nesting of

people within course groups. First, we calculated unconditional models to examine dependence

in the data. A between-group clustering effect was apparent for all aspects of well-being (Wald Z

ranged from 2.14, p = .03 for anxiety symptoms to 3.20, p = .001 for physical function). The

intraclass correlation coefficient, which documents the proportion of total variance in well-being

attributable to course group, ranged from .11 for anxiety symptoms to .23 for physical function.

Hypotheses. To test the hypotheses, we added time of assessment into the multilevel

models as a Level 1 predictor (Week 3 = 0, Week 12 = 1). Improvement was apparent for pain

interference, fatigue, sleep disturbance, anxiety and depressive symptoms, and social

participation, but not physical function or pain intensity (see Model 1 in Table 2). These results


imply mixed support for our logic regarding physical health (H1) and full support for our

predictions regarding mental health (H2) and social health (H3).

Research questions. Next, we included five personal characteristics as Level 1

predictors: (a) role (0 = caregiver, 1 = individual with combat or civilian trauma), (b) gender (0 =

woman, 1 = man), (c) age, (d) number of sessions attended, and (e) graduate status (0 = first

completion of the course, 1 = repeat completion). Those with combat or civilian trauma reported

more anxiety symptoms and less social participation than caregivers (see Model 2 in Table 2).

Men reported worse physical function, pain interference and intensity, sleep disturbance, and

social participation than women. Older participants reported worse physical function and pain

interference, but also less fatigue and anxiety symptoms, than younger participants. People

repeating the course reported more fatigue than those completing it for the first time.

To evaluate the personal characteristics as potential moderators of improvement (RQ1),

we added five interaction terms computed as time of assessment multiplied by each personal

characteristic. Despite the mean-level differences (see Model 2 in Table 2), no statistically

significant interaction effects were apparent. In other words, improvement did not vary by role,

gender, age, the number of sessions attended, or graduate status.

We investigated RQ2 by examining military characteristics as potential moderators of

improvement using the subsample of participants with military combat trauma (n = 146). We

replaced the personal characteristics in the multilevel models with three military characteristics:

(a) military status (0 = veteran, 1 = currently serving), (b) number of months of combat

deployment, and (c) military branch (0 = Navy, Air Force, or Marines, 1 = Army). Findings for

time of assessment indicated that participants with military combat trauma mirrored the full

sample in reporting improvement for pain interference, fatigue, sleep disturbance, anxiety and


depressive symptoms, and social participation (see Table 3). With respect to military

characteristics, veterans reported poorer well-being than currently serving personnel in terms of

physical function, pain interference and intensity, sleep disturbance, and anxiety and depressive

symptoms. Those with more months of combat deployment reported more pain interference and

intensity, sleep disturbance, and depressive symptoms.

One moderation effect emerged when we added the two-way interaction terms. Time of

assessment interacted with military status to predict anxiety symptoms, B = 1.94, p = .02. The

direction of the interaction was such that veterans (Mchange = -2.32, SDchange = 2.97) reported more

improvement than currently serving military personnel (Mchange = -0.78, SDchange = 2.39), t(144) =

2.95, p = .004. In sum, the program was more effective for veterans than for current service

members in terms of anxiety symptoms (RQ2).

Discussion

Combat trauma in general, and the spiritual and psychological wounds of war in

particular, can be debilitating (Fritch et al., 2010; Smith-MacDonald et al., 2017; Wortmann et

al., 2017). Although combat trauma cannot be erased in people’s minds, their perceptions are

potentially malleable (e.g., Vest et al., 2018), which suggests a site of intervention for helping

service members, veterans, and their families move forward. The REBOOT Combat Recovery

program is a 12-week faith-based course led by peer facilitators. Our study involving 254

attendees is the first to examine whether the program is effective. Although caution is warranted

in the absence of a pretest-posttest control group design, the initial findings appear promising.

Implications of the Results

Participants appear to have benefited from the program in clinically meaningful ways.

They reported improvement from Week 3 to Week 12 in pain interference, fatigue, sleep


disturbance, anxiety and depressive symptoms, and social participation. In other words, gains

were apparent for three of the five domains of physical health (H1), both domains of mental

health (H2), and the domain of social health (H3). The two indicators of physical health not

showing statistically significant improvement were physical functioning and pain intensity.

These findings offer initial evidence that the REBOOT program may enhance the well-being of

service members, veterans, and their caregivers, particularly with respect to psychological

functioning and social involvement. In fact, our data suggest improvements in well-being even in

the presence of ongoing problems with physical functioning and pain intensity.

Men, veterans, and those with more months of combat deployment reported worse health

overall, but improvement was largely uniform across a variety of personal and military

characteristics. Improvement did not vary by the personal characteristics of (a) role as a

caregiver versus an individual with combat or civilian trauma, (b) gender, (c) age, (d) attendance,

or (e) previous completion of the course (RQ1). Notably, the findings for the latter two variables

imply that participants may accrue benefits in toto rather than additively by session attendance.

Improvement also did not vary by military characteristics such as months of combat deployment

or military branch, but veterans reported more reduction in anxiety symptoms than current

service members (RQ2), perhaps because some level of anxiety may have adaptive value (e.g.,

Corr, 2011) for those currently serving. Overall, REBOOT Combat Recovery may be broadly

helpful to participants with diverse backgrounds but particularly so for veterans.

Although the spiritual needs of service members can be overlooked in systems of care,

spirituality is a key element of military resilience (Sherman et al., 2015; Smith-MacDonald et al.,

2017). Our data cohere with recent work implying benefits from other interventions addressing

spiritual issues. Building Spiritual Strength (BSS) is a group course led by mental health


providers and chaplains that strives to enhance religious meaning-making among those with

military trauma (Harris et al., 2018). Clinician-administered individual approaches informed by

the cognitive-behavioral therapy tradition include (a) Trauma Informed Guilt Reduction (TrIGR)

therapy, which seeks to diminish feelings of guilt related to war experiences (Norman, Wilkins,

Myers, & Allard, 2014); (b) Acceptance and Commitment Therapy (ACT), which seeks to

promote flexibility in thoughts, emotions, and behaviors (Nieuwsma et al., 2015); (c) Adaptive

Disclosure, which seeks to help people experientially and emotionally process their war

experiences (Litz, Lebowitz, Gray, & Nash, 2016); and (d) Impact of Killing (IOK), which seeks

to reduce the distress of combat veterans responsible for deaths in war (Maguen et al., 2017).

Our results, coupled with promising findings for other programs grounded in similar themes,

suggest that values-based content can be helpful for healing after combat trauma.

Because REBOOT is a peer-led and community-based intervention, our data also imply a

role for nonclinical programs administered outside of mental health care settings. Prior results

are mixed for programs that rely on peers to help service members and veterans cope with mental

health issues. Some studies show no help or harm; others suggest potential benefits (Eisen et al.,

2012; Whybrow, Jones, & Greenberg, 2015). Our data fall into the latter category by implying

that nonclinical peer-led services can be useful for assisting those affected by combat trauma.

Limitations and Directions for Future Research

Despite our results suggesting the effectiveness of the REBOOT program, several

limitations of our study are important to note. First, the research design lacked a control group

for benchmarking success. In the absence of data from people not participating in the program,

conclusions about improvement due to REBOOT remain speculative. Second, the baseline

assessment occurred during the third week of the program, so any gains (or losses) during the


first portion of the course were not represented in the over-time analyses. A true pretest-posttest

control group design (e.g., Morris, 2008) or a retrospective pretest design (e.g., Chang & Little,

2018) would be useful next steps. Third, we lacked comparative data from participants who

withdrew prematurely. Additional work is needed to evaluate whether differences exist between

those who drop out versus complete REBOOT. Finally, we did not assess the fidelity of program

administration across the course leaders. We statistically controlled for differences among course

groups, but information about the uniformity of execution by course leaders would offer more

fine-grained insight.

Other directions for future research involve evaluating the broader effects of spiritually-

focused interventions on combat trauma. Who is drawn to participate in a program such as

REBOOT and how does participation affect their spirituality? What are the mechanisms through

which such interventions provide benefits? Answers to these questions would inform the

theoretical frameworks at the crux of the program (American Occupational Therapy Association,

2014; Bandura, 1986; Prochaska et al., 2008). How long do any effects persist? Such data would

be useful for understanding whether sequenced programming could cement any gains. Finally,

how helpful are spiritual systems of care for coping with intractable challenges such as lingering

guilt (e.g., Norman et al., 2014), moral injury (e.g., Litz et al., 2009), and posttraumatic stress

(e.g., Harris et al., 2018)? Insight into these questions would help policymakers, military

command, practitioners, and community members better assist military personnel, veterans, and

their family members affected by combat trauma.


References

American Occupational Therapy Association. (2014). Occupational therapy practice framework:

Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-

S48. doi:10.5014/ajot.2014.682006

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory.

Englewood Cliffs, NJ: Prentice- Hall.

Baum, C. M., Christiansen, C. H., & Bass, J. D. (2015). The Person-Environment-Occupation-

Performance (PEOP) model. In C. H. Christiansen, C. M. Baum, & J. D. Bass (Eds.),

Occupational therapy: Performance, participation, and well-being (4th ed., pp. 49-56).

Thorofare, NJ: SLACK Incorporated.

Bryan, C. J., Griffith, J. E., Pace, B. T., Hinkson, K., Bryan, A. O., Clemans, T. A., & Imel, Z. E.

(2015). Combat exposure and risk for suicidal thoughts and behaviors among military

personnel and veterans: A systematic review and meta‐analysis. Suicide and Life-

Threatening Behavior, 45, 633-649. doi:10.1111/sltb.12163

Chang, R., & Little, T. D. (2018). Innovations for evaluation research: Multiform protocols,

visual analog scaling, and the retrospective pretest-posttest design. Evaluation & the Health

Professions, 41, 246-269. doi:10.1177/0163278718759396

Cornum, R., Matthews, M. D., & Seligman, M. E. P. (2011). Comprehensive soldier fitness:

Building resilience in a challenging institutional context. American Psychologist, 66, 4-9.

doi:10.1037/a0021420

Corr, P. J. (2011). Anxiety: Splitting the phenomenological atom. Personality and Individual

Differences, 50, 889-897. doi:10.1016/j.paid.2010.09.013

Currier, J. M., Farnsworth, J. K., Drescher, K. D., McDermott, R. C., Sims, B. M., & Albright,


D. L. (2017). Development and evaluation of the Expressions of Moral Injury Scale-Military

Version. Clinical Psychology & Psychotherapy, 25, 474-488. doi:10.1002/cpp.2170

Dennis, P. A., Dennis, N. M., Van Voorhees, E. E., Calhoun, P. S., Dennis, M. F., & Beckham, J.

C. (2016). Moral transgression during the Vietnam War: A path analysis of the

psychological impact of veterans’ involvement in wartime atrocities. Anxiety, Stress, &

Coping, 30, 188-201. doi:10.1080/10615806.2016.1230669

Drescher, K. D., Foy, D. W., Kelly, C., Leshner, A., Schutz, K., & Litz, B. (2011). An

exploration of the viability and usefulness of the construct of moral injury in war veterans.

Traumatology, 17, 8-13. doi:10.1177/1534765610395615

Eisen, S. V., Schultz, M. R., Mueller, L. N., Degenhart, C., Clark, J. A., Resnick, S. G., …

Sadow, D. (2012). Outcome of a randomized study of a mental health peer education and

support group in the VA. Psychiatric Services, 63, 1243-1246. doi:10.1176/appi.ps.201100348

Fritch, A. M., Mishkind, M., Reger, M. A., & Gahm, G. A. (2010). The impact of childhood

abuse and combat-related trauma on postdeployment adjustment. Journal of Traumatic

Stress, 23, 248-254. doi:10.1002/jts.20520

Harris, J. I., Usset, T., Voecks, C., Thuras, P., Currier, J., & Erbes, C. (2018). Spiritually

integrated care for PTSD: A randomized controlled trial of “Building Spiritual Strength.”

Psychiatry Research, 267, 420-428. doi:10.1016/j.psychres.2018.06.045

Hays, R. D., Spritzer, K. L., Schalet, B. D., & Cella, D. (2018). PROMIS®-29 v2.0 profile

physical and mental health summary scores. Quality of Life Research, 27, 1885-1891.

doi:10.1007/s11136-018-1842-3

Herzog, J. R., Everson, R. B., & Whitworth, J. D. (2011). Do secondary trauma symptoms in

spouses of combat-exposed National Guard soldiers mediate impacts of soldiers’ trauma


exposure on their children? Child and Adolescent Social Work Journal, 28, 459-473.

doi:10.1007/s10560-011-0243-z

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004).

Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The New

England Journal of Medicine, 351, 13-22. doi:10.1056/NEJMoa040603

Jakob, J. M. D., Lamp, K., Rauch, S. A. M., Smith, E. R., & Buchholz, K. R. (2017). The impact

of trauma type or number of traumatic events on PTSD diagnosis and symptom severity in

treatment seeking veterans. Journal of Nervous and Mental Disease, 205, 83-86.

doi:10.1097/NMD.0000000000000581

Jonas, W. B., O’Connor, F. G., Deuster, P., Peck, J., Shake, C., & Frost, S. S. (2010). Why total

force fitness? Military Medicine, 175, 6-13. doi:10.7205/MILMED-D-10-00280

Kimbrel, N. A., Meyer, E. C., DeBeer, B. B., Mitchell, J. T., Kimbrel, A. D., Nelson-Gray, R., &

Morissette, S. B. (2016). Reinforcement sensitivity and social anxiety in combat veterans.

Personality and Individual Differences, 98, 171-175. doi:10.1016/j.paid.2016.04.008

Litz, B. T., Lebowitz, L., Gray, M. J., & Nash, W. P. (2016). Adaptive disclosure: A new

treatment for military trauma, loss, and moral injury. New York, NY: Guilford.

Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009).

Moral injury and moral repair in war veterans: A preliminary model and intervention

strategy. Clinical Psychology Review, 29, 695-706. doi:10.1016/j.cpr.2009.07.003

Maguen, S., Burkman, K., Madden, E., Dinh, J., Bosch, J., Keyser, J., . . . Neylan, T. C. (2017).

Impact of killing in war: A randomized, controlled pilot trial. Journal of Clinical Psychology,

73, 997-1012. doi:10.1002/jclp.22471

Morris, S. B. (2008). Estimating effect sizes from pretest-posttest-control group designs.


Organizational Research Methods, 11, 364-386. doi:10.1177/1094428106291059

Morris, S. B., & DeShon, R. P. (2002). Combining effect size estimates in meta-analysis with

repeated measures and independent-groups designs. Psychological Methods, 7, 105-125.

doi:10.1037//1082-989X.7.1.105

Nieuwsma, J. A., Walser, R. D., Farnsworth, J. K., Drescher, K. D., Meador, K. G., & Nash, W.

P. (2015). Possibilities within acceptance and commitment therapy for approaching moral

injury. Current Psychiatry Reviews, 11, 193-206. doi:10.2174/1573400511666150629105234

Norman, S. B., Wilkins, K. C., Myers, U. S., & Allard, C. B. (2014). Trauma informed guilt

reduction therapy with combat veterans. Cognitive and Behavioral Practice, 21, 78-88.

doi:10.1016/j.cbpra.2013.08.001

Owens, E., & Owens, J. (2016). REBOOT Combat Recovery leader handbook. Fort Campbell,

KY: REBOOT Combat Recovery.

Pratt, C. C., McGuigan, W. M., & Katzev, A. R. (2000). Measuring program outcomes: Using

retrospective pretest methodology. American Journal of Evaluation, 21, 341-349.

Prochaska, J. O., Wright, J. A., & Velicer, W. F. (2008). Evaluating theories of health behavior

change: A hierarchy of criteria applied to the transtheoretical model. Applied Psychology, 57,

561-588. doi:10.1111/j.1464-0597.2008.00345.x

Purcell, N., Koenig, C. J., Bosch, J., & Maguen, S. (2016). Veterans’ perspectives on the

psychosocial impact of killing in war. The Counseling Psychologist, 44, 1062-1099.

doi:10.1177/0011000016666156

Shea, M. T., Presseau, C., Finley, S. L., Reddy, M. K., & Spofford, C. (2017). Different types of

combat experiences and associated symptoms in OEF and OIF National Guard and reserve

veterans. Psychological Trauma, 9(S1), 19-24. doi:10.1037/tra0000240


Sherman, M. D., Harris, J. I., & Erbes, C. (2015). Clinical approaches to addressing spiritual

struggle in veterans with PTSD. Professional Psychology: Research and Practice, 46, 203-

212. doi:10.1037/pro0000020

Smith-MacDonald, L., Norris, J. M., Raffin-Bouchal, S., & Sinclair, S. (2017). Spirituality and

mental well-being in combat veterans: A systematic review. Military Medicine, 182, e1920-

e1940. doi:10.7205/MILMED-D-17-00099

Stein, N. R., Mills, M. A., Arditte, K., Mendoza, C., Borah, A. M., … Resick, P. A. (2012). A

scheme for categorizing traumatic military events. Behavior Modification, 36, 787-807.

doi:10.1177/0145445512446945

Thomas, K. H., McDaniel, J. T., Albright, D. L., Fletcher, K. L., & Koenig, H. G. (2018).

Spiritual fitness for military veterans: A curriculum review and impact evaluation using the

Duke Religion Index (DUREL). Journal of Religion and Health, 57, 1168-1178.

doi:10.1007/s10943-018-0597-z

Vest, B. M., Homish, D. L., Hoopsick, R. A., & Homish, G. G. (2018). What drives the

relationship between combat and alcohol problems in soldiers? The roles of perception and

marriage. Social Psychiatry and Psychiatric Epidemiology, 53, 413-420.

doi:10.1007/s00127-017-1477-7

Whybrow, D., Jones, N., & Greenberg, N. (2015). Promoting organizational well-being: a

comprehensive review of Trauma Risk Management. Occupational Medicine, 65, 331-336.

doi:10.1093/occmed/kqv024

Wortmann, J. H., Eisen, E., Hundert, C., Jordan, A. H., Smith, M. W., Nash, W. P., & Litz, B. T.

(2017). Spiritual features of war-related moral injury: A primer for clinicians. Spirituality in

Clinical Practice, 4, 249-261. doi:10.1037/scp0000140


Table 1

Descriptive Statistics and Paired Comparisons by Time of Assessment

______________________________________________________________________________

Week 3 Week 12

Mt (SDt) a Mt (SDt) a t(253) d

Physical Function 17.21 (3.56) .93 17.23 (3.34) .92 -0.11 .01

Pain Interference 9.32 (4.63) .97 8.56 (4.31) .97 3.54 *** .22

Pain Intensity 3.58 (2.62) -- 3.25 (2.47) -- 2.75 *** .17

Fatigue 11.92 (4.09) .94 10.36 (3.89) .94 7.34 *** .45

Sleep Disturbance 12.51 (3.86) .87 11.26 (3.71) .88 6.66 *** .41

Anxiety Symptoms 11.13 (3.64) .90 9.45 (3.11) .89 8.92 *** .53

Depressive Symptoms 10.15 (4.00) .93 8.34 (3.38) .93 8.58 *** .51

Social Participation 13.39 (3.91) .91 14.66 (3.75) .94 -6.41 *** .39

______________________________________________________________________________

Note. N = 254 participants. M and SD are reported in the raw metric, a is Cronbach’s measure of

internal consistency, paired-samples t test values indicate within-person change from Week 3 to

Week 12, and d is the absolute value of the effect size corrected for the correlation between

Week 3 and Week 12.

*** p < .001.


Table 2

Multilevel Modeling Results for Time of Assessment and Personal Characteristics Predicting Well-Being

___________________________________________________________________________________________________________

Physical Pain Pain Fatigue Sleep Anxiety Depressive Social Function Interference Intensity Disturbance Symptoms Symptoms Participation ___________________________________________________________________________________________________________

Model 1

Time of Assessment 0.02 -0.78 * -0.34 -1.55 *** -1.30 *** -1.69 *** -1.83 *** 1.28 ***

Model 2

Time of Assessment

-0.02

-0.79 *

-0.34

-1.43 ***

-1.21 ***

-1.62 ***

-1.81 ***

1.20 ***

Role -0.44 0.35 0.34 0.64 0.51 1.02 * 0.61 -1.10 *

Gender -1.25 ** 1.58 ** 0.87 ** 0.52 1.02 * 0.55 0.77 -0.91 *

Age -0.03 * 0.04 * 0.01 -0.05 ** -0.03 -0.04 ** -0.01 -0.01

Number of Sessions -0.08 0.19 0.10 -0.01 0.11 0.14 0.22 -0.01

Graduate Status -0.80 0.57 -0.08 1.89 ** 0.79 -0.39 -0.14 -0.95

____________________________________________________________________________________________________________

Note. N = 508 observations (two waves of data from 254 participants). Cell entries are unstandardized coefficients. Time of

assessment was coded 0 = Week 3, 1 = Week 12. Role was coded 0 = caregiver, 1 = person who had experienced trauma. Gender was

coded 0 = woman, 1 = man. Graduate status was coded 0 = first completion of the course, 1 = repeat completion of the course.

* p < 05. ** p < 01. *** p < .001.


Table 3

Multilevel Modeling Results for Military Characteristics Predicting Well-Being

____________________________________________________________________________________________________________

Physical Pain Pain Fatigue Sleep Anxiety Depressive Social Function Interference Intensity Disturbance Symptoms Symptoms Participation ____________________________________________________________________________________________________________

Time of Assessment -0.02 -1.16 * -0.35 -1.45 ** -1.10 ** -1.72 *** -1.84 *** 1.41 ***

Military Status 1.57 * -2.00 ** -1.24 ** 0.20 -1.33 * -1.20 * -2.04 ** 0.72

Months Deployed -0.02 0.06 ** 0.04 *** 0.02 0.03 * 0.02 0.06 *** -0.03

Military Branch -0.83 0.11 0.05 -1.03 -0.51 -0.38 -0.44 0.90

Note. n = 292 observations (two waves of data from 146 service members). Cell entries are unstandardized coefficients. Time of

assessment was coded 0 = Week 3, 1 = Week 12. Military status was coded 0 = veteran, 1 = currently serving. Military branch was

coded 0 = Navy, Air Force, or Marines, 1 = Army.

* p < 05. ** p < 01. *** p < .001.

Running head: EVALUATING THE EFFECTIVENESS 1 · Jenny L. Owens REBOOT Combat Recovery Matthew B....

Documents

Transcript of Running head: EVALUATING THE EFFECTIVENESS 1 · Jenny L. Owens REBOOT Combat Recovery Matthew B....